Knowledge, attitude and practices of residents toward antimicrobial usage and resistance in Gondar, Northwest Ethiopia

Background Antimicrobials are essential for human and animal health. Drug resistance to an antimicrobial agent follows the introduction of a new antimicrobial agent. Evidence suggests that the public plays an important role in the risk, increase, and spread of antimicrobial resistance. This study aimed to assess the knowledge, attitudes, and practices of the Gondar City residents regarding antimicrobial use and resistance. Methods A cross-sectional study was conducted from April to July 2021 on 400 randomly selected Gondar city residents using a pretested semi-structured questionnaire. The descriptive and chi-square tests were used to analyse the data. Results The response rate was one hundred percent. Approximately 75% of respondents were men, with 32% having completed secondary school. Nearly 74% and 35% of participants were married and worked in various government jobs. Furthermore, 48%, 54%, and 50% of respondents, respectively, had moderate knowledge, a positive attitude, and good practice concerning antimicrobial use and resistance. The chi-square analysis revealed a significant (p < 0.05) disparity between knowledge and educational level, marital status, and position in the house. The respondents’ attitude levels were also significantly associated (p < 0.05) with their educational level, marital status, occupation, and position in the house. Respondents’ practice levels were also significantly associated (p < 0.05) with their educational level and occupation. The study also found a significant relationship between respondents’ knowledge and attitude (χ2 = 215.23, p ≤ 0.01), knowledge and practice (χ2 = 147.2, p ≤ 0.01), and attitude and practice (χ2 = 116.03, p ≤ 0.01). Conclusion This study found that study participants had some misconceptions about antimicrobial use and resistance. As a result, both enforcing antimicrobial regulation and educating people about antimicrobial use are advised. Supplementary Information The online version contains supplementary material available at 10.1186/s42522-022-00066-x.


Introduction
Microbes have been around for a million years and are one of the oldest creatures on the planet. While other advanced, massive ancient animals and plants perished, these tiny microorganisms adapted, developed, and survived throughout the eras. On the other hand, microbes are thought to be some of nature's most adaptable and successive creatures. Since that time, these microbes have been subjected to antibiotics derived from other microorganisms, such as Penicillium notatum [1]. Furthermore, hundreds of natural, semi-synthetic, and synthetic antimicrobial molecules are used to treat infections in both humans and animals [2]. These antimicrobials have been widely used in animals for disease prevention, control, and treatment, as well as growth promoters. Antimicrobial drug use has become widespread over several decades, and these drugs have been widely misapplied in both humans and food-producing animals in ways that promote the selection and spread of resistant microbes [3].
Misuse and overuse of various antimicrobial agents in the health care setting and the agricultural industry are regarded as major contributors to the emergence of antimicrobial resistance. Besides that, spontaneous evolution, pathogen mutation, and the transmission of resistant genes via horizontal gene transfer are significant contributors to antimicrobial resistance [4]. More than half of all medicines are prescribed, dispensed, or sold improperly and do not follow the principle of rational drug use, and more than half of patients fail to take them correctly. This erroneous dose leads to an increase in antimicrobial resistance. Despite ongoing efforts to improve antimicrobial prescribing and address issues such as self-prescribing, unnecessary use for viral infections, dosing errors, and excessive treatment durations, the global rate of antimicrobial-resistant infections is increasing [5].
Antimicrobial resistance and the rise in MDROs globally are associated with increased morbidity and mortality, cross-transmission within and between healthcare settings, and increased consumption of limited patientcare resources. Despite increased awareness, the publication of antimicrobial stewardship guidelines, and a variety of initiatives, the proportion of resistant strains causing both health-care and community-associated infections continues to rise, while the number of new antimicrobials continues to fall [6].
In general, antimicrobial resistance is a global public health concern that has been exacerbated by the overuse of antimicrobials around the world [7]. Further to that, it is a major concern for most African countries with low and middle incomes, which are associated with poverty, a high prevalence of infectious diseases, and uncontrolled antimicrobial use in animals and humans [8,9]. There is little information available about antimicrobial use and resistance in Ethiopia. Similarly, some studies show that inappropriate antibiotic use is linked to a variety of factors such as a low education level, job engagement, and a lack of knowledge about the use of human antibiotic preparations to treat animals [10,11]. However, it is questionable to what extent knowledge, attitudes, and behavioural practices regarding animal and human antimicrobial usage and resistance are in the study area. Thus, the study of human and animal antimicrobial usage and resistance in the study area contributes to the condition by identifying the factors that contribute to a low level of knowledge, attitudes, and behavioural practices, thus allowing the community to be aware of the condition and apply possible intervention measures to reduce the risks. As a result, the purpose of this study was to assess residents' knowledge, attitudes, and behavioural practices regarding antimicrobial usage and resistance in Gondar, northwest Ethiopia.

Study area
The study was conducted in Gondar, a city in northwest Ethiopia, 740 kilometres from the capital, Addis Ababa. The city is a historic and tourist destination in the country. The city's elevation ranges from 1800 to 2200 meters above sea level. It receives 1000 millimetres of rain per year on average. The city's annual maximum and minimum temperatures are 30.7°C and 22°C, respectively, with an overall average temperature of 26°C. The relative humidity in the city ranges from 60% to 70% during the rainy season and from 30% to 40% during the dry season. Gondar had a population of 500,788, with 300,000 men and 200,788 women [12].

Study design
From April to July 2021, a cross-sectional study was conducted in Gondar, Northwest Ethiopia, to assess residents' knowledge, attitude, and behavioural practices regarding human and animal antimicrobial use and resistance. The study was conducted following the Helsinki Declaration as well as national and institutional standards.

Study population and sample size
The source population consisted of adults of both genders who were at least 18 years old and lived in Gondar city. Thrusfield's formula for a single population was used to determine the number of samples included in this study [13]. The 95% confidence interval, 5% marginal error, and 50% for antimicrobial use during the past twelve months were considered to calculate the sample size. As a result, 384 people from Gondar city were included in the study. However, after accounting for a 5% non-response rate, the final sample size was 400. To select study participants, a random sampling method with a lottery system was used.

Data collection and tools Data collection
For data collection via interview, a semi-structured questionnaire was used. The questionnaire was developed after reviewing the literature on how to conduct a KAP survey as well as global antimicrobial studies. The questionnaire consisted of four sections, with the majority of the questions being closed-ended. Two epidemiology and public health experts reviewed the questionnaire items for content validity. Based on expert feedback and recommendations, questionnaire items were modified to better suit the local population. Furthermore, before data collection, participants in this study were given verbal information to inform them of the purpose of the study, and they were free to leave the interview at any time. Furthermore, all the data will be kept securely.

Measurement tools
Antimicrobial usage and resistance knowledge Nine questions were asked to determine the residents' level of knowledge concerning antimicrobial use and resistance. Six of the questions were on a Likert scale, while the other three were open-ended, allowing respondents to express their opinions. The answers to closed-ended questions were scored as 3 (correct answer), 2 (uncertain answer), and 1 (no answer or for a wrong answer). The scores ranged from 6 to 18 points, and they were categorized into three levels based on Bloom's cut-off point of 60-80%, as follows: High level (80-100%) 15-18 points; Moderate level (60-79%) 11-14 points and a low level (less than 60%) 6-10 points [14].
Attitude toward antimicrobial usage and resistance There were eight questions, one positive and seven negative statements, with Likert scale answers ranging from "agree" to "disagree. " A knowledge scale was used to assess the rating scale. The scores ranged from 8 to 24, and all individual responses were summed and calculated for means. The results were categorized into three (positive attitude, neutral attitude, and negative attitude). Positive attitudes ranged from 19-24 (80-100%), neutral attitudes ranged from 15-18 (60-79%), and negative attitudes ranged from 8-14 (less than 60%) [14].
Antimicrobial stewardship and resistance This section contained eleven questions. There were ten closedended questions, eight Likert questions, one yes-or-no, one multiple-choice question, and one open-ended question. The previous rating scale was used to assess the responses. The scores in measuring antimicrobial usage and resistance ranged from 8 to 24 and were classified into three levels based on Bloom's cut-off point of 60-80% [14]. The levels of practice were good (80-100%) of 19-24 scores, fair (60-79%) of 15-18 scores, and poor (less than 60%) of 8-14 scores [14].

Data management and analysis
The collected data was classified, filtered, and coded using Microsoft Excel ® 2010. The information was then exported to STATA version 16 (Stata Corp., Texas, USA) for statistical analysis. The socio-demographic characteristics of the study participants were shown using descriptive statistics. The numerical data were expressed as mean ± standard deviation or percentage when appropriate. The chi-square test (c2) was used to test the relationship between knowledge, attitude, and practice to identify the most important demographic factors. When the p-value is less than 0.05, the data is considered significant.

Socio-demographic characteristics of respondents
The analysis of demographic parameters revealed that the vast majority of participants 301 (75.25%) were males, 128 (32%) were secondary school graduates, 294 (73.5%) were married, and 139 were employed in various government careers (34.75%). The average age of the study subjects was 43.85 years, with a standard deviation of 13.48 years (Table 1).

Respondents' knowing of antimicrobial use and resistance
The respondents' mean knowledge score was 13.137 out of a possible 18 points (SD = 3.008). What's more, approximately 48% of respondents had "moderate knowledge, " 35% had "high knowledge, " and 17% had "low knowledge" about antimicrobial resistance and usage. Alternatively, as shown in Table 2, 54.5% of respondents were aware that antimicrobials were effective against bacteria. Similarly, half of the participants (51.5%) agreed that antimicrobials help with cold recovery. Approximately 47% disagree that antimicrobials are effective against the virus.

Respondents' attitudes toward antimicrobial use and resistance
More than half of the study participants (53.75%) were found to have a "positive attitude, " 27.25% had a "neutral attitude, " and 19% had a "negative attitude" toward AMU and AMR. The mean attitude score for all respondents was 18.06 out of a possible 24 points (SD = 3.7).
According to Table 3, half of the respondents agreed with the statement "to finish the course of treatment with AM even if they feel better. " About 35% of those polled agreed that they would seek antimicrobials from relatives or friends rather than from health care providers. However, more than half of the respondents (60.75%) disagreed with this statement. Similarly, the majority (74%) of respondents had a positive attitude (disagree) toward the statement, "I prefer to be able to buy antimicrobials from the pharmacy without a prescription", and eightysix (21.5%) of respondents agreed to do so, while nineteen (4.75%) remained uncertain. In addition, with the statement stated: "When I have a minor illness, I prefer to use an antimicrobial and feel better quickly," thirty-seven percent of respondents (148) agreed, 79 (19.75%) were unsure, and 173 (43.25%) disagreed (See Table 3).

Respondents' antimicrobial use and resistance practices
All respondents had a mean practice score of 17.96 out of a possible 24 points (SD=2.73). Approximately half of the participants had a good practice, 39% had fair practice, and 11.25% had poor practice.
Two hundred seventy (54.25%) of those questioned said they always consult a doctor before beginning antimicrobial therapy. However, 42 (10.5%) of the participants took antimicrobials without consulting a health professional. Of the study participants, 61.25% always completed the full course of their antimicrobial treatment, 16.25% sometimes did, and 22.5% never finished. Furthermore, 60.5% of animal owners had never treated their animals with an antimicrobial prescribed for humans. However, 28% and 11.5% of respondents, respectively, treated their animals with antimicrobials prescribed for humans. Half of the respondents (50%) confirmed that they always complete the full course of treatment for their animals, 28.25% occasionally, and 21.75% never (Table 4).

Relationship between respondents' knowledge, attitude and practice
Respondent knowledge was found to have a significant relationship with respondents'attitudes toward AMR and AMU (χ2 = 215.23, p < 0.01). The proportion of respondents with positive attitudes rises as their level of knowledge rises (Sup Table 1). Similarly, a significant association (χ2 = 147.2, p < 0.01) was found between respondents' knowledge and practice (Sup Table 2). It implied that, as the study participants' level of knowledge of AMU and AMR increased, so did the proportion of respondents with good practice. Furthermore, a significant interaction (χ2 = 116.03, p < 0.01) was observed between respondents' attitudes and good practices regarding AMU and AMR. It suggests that respondents'attitudes have a direct influence on their level of practice (Sup Table 3).

Discussion
Inappropriate AMU and the associated risk of AMR are a growing public health issue worldwide [15][16][17]. The misuse and abuse of antimicrobials in agriculture, veterinary medicine, and human medicine have been identified as major contributors to the global spread of AMR [18][19][20]. The emergence and spread of antimicrobial-resistant pathogens impede the use of antibiotics for both preventative and therapeutic purposes. This issue is becoming more prevalent in lowincome African countries [19,21]. On the other hand, the use of antimicrobials can be affected by the interaction of knowledge and expectations of users and prescribers as well as the economic, health systems and environmental factors of the communities [16]. As a result, a questionnaire survey was used in this study to assess knowledge, practices, and attitudes toward AMU and AMR in Gondar City, Ethiopia. Knowledge, attitudes, and practices concerning antimicrobial use and resistance are critical for combating global antimicrobial resistance [22].
According to the findings of the current study, the majority of participants (72.3%) are aware of what antimicrobials are, but only 36.3% are conscious of what they are used for. Amoxicillin was the most commonly used antibiotic among the study participants. The current finding is consistent with the findings of Gebeyehu et al. [10] in Bahir Dar, Ethiopia; Widayati et al. [23] and Karuniawati et al. [24] in Indonesia; Sindato et al. [18] in Tanzania; Ocan et al. [25] in Uganda; and Ramay et al. [26] in Guatemala, all of whom found that Amoxicillin was the most commonly used antibiotic.
Understanding which conditions can be treated with antibiotics is also important, as using antibiotics for conditions that are not treatable with these medications  The effectiveness of antimicrobials is better if they are newer and more costly (A new brand than the common one and more expensive than the usual antimicrobials). contributes to misuse and, as a result, resistance development [23]. People in Gondar who participated in the study had sufficient knowledge (54.5%) to answer questions about whether antimicrobials are effective against bacteria, but this is lower than the previous studies in Germany [27] and Malaysia [28], which found that 83.7% and 76.7% of participants, respectively, correctly identified antibiotics as effective against bacteria. However, in the current study, some respondents (20%) are unsure whether antimicrobials are effective against bacteria, which is consistent with Kuwait (25.3%) [29]. Some attribute this lack of knowledge to the common use of the term "germ" rather than the microbiological terms "bacteria" or "virus" during counselling or the provision of medical advice to the public or patients. Poverty is also a major driver of AMR development in both developing and developed countries. In developing countries, factors such as insufficient access to effective drugs, unregulated antimicrobial dispensing and manufacture, and insufficient antimicrobial treatments due to cost contribute to the development of AMR [21]. According to a large number of participants (48.5%) in this study, the use of antimicrobials can increase bacterial resistance to them. This supports the findings of Tesfaye [30] in Bahir Dar, Ethiopia; Pereko et al. [31] in Namibia; Jifar and Ayele [32] in Harar, Ethiopia, and Darwish et al. [33] in Jordan, where 69.7%, 72%, 78.3%, and 50% of respondents believed, respectively. As a result, this finding indicates that the majority of those who took part in the study were well-versed in the risks associated with the use of antimicrobials. Antimicrobial agents are widely used in animal production systems in Ethiopia, as in other Sub-Saharan countries. On the other hand, the evidence on antimicrobial use is limited and anecdotal [34]. Antimicrobial resistance must be addressed through a variety of interventions, including interventions that reduce inappropriate and unnecessary antimicrobial use in humans and animals while also ensuring that effective antimicrobial therapy is available when needed [20,35].
The effectiveness of antimicrobials is jeopardized by antimicrobial resistance, which can arise from discontinuing the entire course of treatment. According to studies, the reasons for the discontinuation of antimicrobials are a lack of knowledge about and awareness of antimicrobial use [10]. The participants' attitude toward antimicrobial use and resistance was unavoidable and restrictive in this study. As a result, half of the respondents (50.5%) acknowledged the importance of continuing to take their prescribed medication even after they felt better. While approximately 40% of respondents believed that patients should discontinue treatment as soon as they felt better, this finding is higher than the study done in Bahir Dar, Ethiopia by Gebeyehu et al. [10], which reported 27%, and lower than the reports of Dyar et al. [35] in Kuwait, Sakr et al. [36] in Lebanon, and Darwish et al. [33] in Iraq, which reported that 45-60% of respondents, respectively, believed that patients should stop their treatment as soon as they felt better. Because of this misunderstanding in antimicrobial use, the patient is at risk of relapse with pathogenic bacteria resistance. Inadequate dosing, incomplete courses, and indiscriminate drug use have all contributed to the emergence and spread of antimicrobial resistance, which is now a problem in several countries [15]. Similarly, we practice self-medication every day in the form of self-care for our health. Self-medication refers to the use of drugs, herbs, or home remedies on one's initiative or the advice of another person, without first consulting a doctor [37]. In this study, 54.25% of study participants had a positive attitude because they never took antimicrobials without first consulting with their doctor. However, 10.5% of them did not develop such an attitude and preferred to consult with and obtain antimicrobials from other sources. The current finding was lower than reports from other countries, including the UAE [38], Lebanon [39], Iraq [40], Palestine [41], Jordan [42], and Yemen [43]. Meanwhile, it was higher than reported by You et al. [44] in Hong Kong, McNulty et al. [45] in the United Kingdom, Ling Oh et al. [28] in Malaysia, Zajmi et al. [46] and Widayati et al. [23] in Indonesia, who reported attitude levels ranging from 4.8-9%. The observed differences in the studies were attributed to differences in sample size, education level, and sociodemographic characteristics of the study participants.
Furthermore, leftover antibiotics at home are major sources of medicine in many countries for emergency or future use issues [47]. In this study, 15% of respondents agreed that they keep leftover antimicrobials at home in case they need them in the future. The findings are comparable to Jifar and Ayele's report in Harar, Ethiopia  [32]. The current finding, however, was lower than that of a study conducted in Malaysia [48], Namibia [31], Jordan [33], India [17] and Egypt [49]. Disparities between studies could be attributed to differences in study participants' awareness and education levels. Moreover, significant associations (p < 0.05) between various socio-demographic factors and KAP scores were noticed in the current study. Antimicrobial knowledge scores tended to rise as one's level of education increased. Similarly, participants with a college or university education, a secondary education, or a vocational education had higher knowledge scores than those with only primary education or no formal education. It corroborates the findings of Bhardwaj et al. [17] in India, Sindato et al. [18] in Tanzania, Geta and Kibret [20] in Ethiopia and Karuniawati et al. [24] in Indonesia. There was also a statistically significant (p < 0.05) relationship found between respondents' knowledge and practice, knowledge and attitude, and practice and attitudes. As a result, it implied that as study participants' knowledge of AMU and AMR increased, so did the proportion of respondents who practised and behaved well.
It is also necessary to describe the current study's limitations. The information gathered was self-reported and based on the respondents' memories, so it is subjective. The results could be underestimated or overestimated, resulting in recall bias. Furthermore, the quality of interview-based data may have been influenced by recall bias and the decision to share desirable and undesirable community practices. What's more, the role of some relevant explanatory factors in our analysis was not ruled out. For example, household income status was not taken into account in this study. The study was also conducted in a small area with a snapshot approach, which may have resulted in selection bias because approximately 25% of the respondents were females. As a result, drawing generalizable conclusions from the results will be difficult. The findings, however, may apply to areas with similar settings.

Conclusion
The current study's findings indicate that there is some appropriate knowledge about antimicrobial usage and resistance. However, there were misunderstandings and a lack of knowledge about antimicrobial use, with respondents believing that antimicrobials were used to treat the common cold. Respondents demonstrated good practice, particularly in the use of antimicrobials, with the majority consulting a doctor before taking antimicrobials and refusing to take them from friends or pharmacies without a prescription. Meanwhile, there was a significant error in not taking the full dose of treatment. This malpractice reflected the public's lack of knowledge and incorrect beliefs about the prudent use of antimicrobials. Respondents with a high educational level have good knowledge and understanding. This study's findings are important because they provide valuable information for developing an intervention in public health promotion to improve knowledge, attitudes, and practices about antibiotics.
To promote the prudent use of antibiotics, educational interventions on antibiotic use and its relationship with drug resistance are required, as is a Ministry of Health policy to increase knowledge and awareness about antibiotics, which includes mass media advertising.